Neck rejuvenation by direct anterior medial cervicoplasty: the modified zigzag-plasty according to Tschopp.

BACKGROUND: Conventional cervicofacial rhytidectomy has become the standard treatment of skin excess of the ageing neck. However, some patients want to avoid an extensive surgical procedure, especially if the anterior neck is the predominant problem zone. OBJECTIVE: To report on the efficacy and safety of a zigzag-shaped skin excision combined with platysma plication. METHODS AND MATERIALS: We present a retrospective case review series of six female patients. Skin excess was marked preoperatively using the skin pinching technique, then transferred to a zigzag-shaped area and finally excised using the method according to Tschopp, which is described. Patients were followed up for at least 1 year. RESULTS: All patients (age: 55-82 years, median: 65 years) were very satisfied with the results. On an overall patient satisfaction scale of 1-10 (1 being the best), the scars were graded on average 1.85 (median: 2) 1 year after surgery. No scar hypertrophy, functional impairment, nerve damage or other serious complications were observed. CONCLUSION: In selected patients, the direct anterior zigzag-shaped excision poses an effective, safe and easy surgical option for both skin excess and fat excess and platysma banding. The technique is easily reproducible, with low morbidity and high patient satisfaction.

Monophasic synovial sarcoma of posterior pharyngeal wall: a rare case report with unique reconstruction using lateral trapezius flap.

Synovial sarcoma is a rare entity to be encountered in the head and neck region and is always a challenge in terms of diagnosis, treatment planning and reconstruction of the surgical defect. In our case, we faced a similar challenge for diagnosis and also have ventured for lateral trapezius flap as a new reconstructive option for such bulky tumour defects. We hereby present a 25-year old male patient with monophasic synovial sarcoma of posterior pharyngeal wall. The radiological and clinicopathological features along with various diagnostic tests and treatment options are discussed.

The Horizontal Neck Lift.

The horizontal neck lift is a procedure involving direct excision of a horizontally oriented ellipse of skin from the neck. This procedure was developed for neck rejuvenation in patients with significant horizontal creases and excess skin of the middle and lower neck, areas that often cannot be adequately addressed with traditional techniques. This article describes the procedure, indications, patient counseling, and postoperative care in detail from the senior author's (H. M.) experience.

The Difficult Neck in Facelifting.

As the popularity and acceptance of facial and cervical rejuvenation procedures grows, surgeons are increasingly encountering patients with less favorable anatomical characteristics for rhytidectomy. These patients will typically display an obtuse cervicomental angle, underprojected chin, excess cervical adiposity, and platysmal banding, in addition to ptotic submandibular glands, tenacious jowls, and prejowl volume deficits. Recognition of these problems and the correct application of available techniques to address the difficult neck in facelifting are critical in maximizing success.

[Cervical lift: An update]. / Le lifting cervical : évolutions récentes.

The neck is an aesthetic unit for which a rejuvenation request is sometimes very targeted or ore often encompassed in a global surgical project of face-lift. To obtain a long lasting outcome, the plastic surgeon has to make a full, detailed, and exhaustive analysis of the neck in order to choose the best indication within the multiple surgical tools. A full clinical examination is the key point, every aspects are outlined. The numerous surgical choices are described, illustrated, and sometimes revisited in the light of targeted anatomical studies. A didactic and graduated way is used to explain the recent evolutions of the surgical tools of the cervical lifting. Complications and insufficiencies in outcomes must be identified and explained. Finally, we illustrate this development by clinical cases. The surgical improvement of the cervical region is, for us, centered on the reconstruction of a cervical retaining structure: the Cervico-Mandibular Angle Suspensor (CMAS) ligament. This element makes it possible to understand and integrate the large number of technical proposals for cervical lifting.

[Clinical analysis before surgery in facial and neck rejuvenation]. / Analyse clinique avant chirurgie de rajeunissement cervico-facial.

The first step to determine a medical or surgical intervention is the clinical exam. The clinical exam is the paramount step to provide a treatment plan that can be modified and individualized accounting the patient preferences. During the consultation for facial rejuvenation, attention should be paid to understand the patient's motivation and expectations. A thorough understanding of the anatomy and the natural history of ageing will facilitate the analysis of the face. Not only the degree of ptosis but also the degree of volume loss will need to be assessed, as well as the influence of the facial muscles, the skin quality, and the different causes of rythids. The comprehensive age-related anatomical changes are often perceived and described as tiredness or sadness. Patients very commonly only point out a single anatomical region. During the consultation, the surgeon should provide the patient with the information of the comprehensive interplay of the different anatomical regions and their individual ageing process. Obtaining a harmonious, natural appearing outcome is the result of excellent surgical skills and applied knowledge. The clinical exam should also find out traps and technical difficulties. Although standardized photographs allow a static evaluation of one's result, video may deliver additional information about the postoperative result, and may contribute to the understanding of the technique used. Spending the additional time by performing a thorough facial analysis and preoperative planning is well-invested time. Having a good understanding of the possible surgical improvements and limitations will be beneficial for both, the patient and the surgeon. Managing the expectations of the patient and careful preoperative planning will increase patient's satisfaction. At the same time, the surgeon will able to critically assess his/her own result and taking pleasure improving their own technique.

[Care and optimal management of the face- and neck-lift patients]. / Prise en charge et gestion des patients demandeurs d'un lifting cervico-facial.

Surgical and case management for patients demanding a face- and neck-lift are very important. The purpose of this paper is to help the plastic surgeons with information and recommendations useful for the best medical care of patients requiring a face- and neck-lift. The first consultation is the most important contact with the patient. The preoperative discussion helps to define patient demands and to evaluate eventual contraindications for surgery. The clinical exam and patient requirements are useful in the construction of the therapeutic proposition. This proposition is then confronted with patients' expectations and demands. The confrontation between the surgical proposition and patients' expectations allows to evaluate if it is appropriate, or not, to operate. At the end of the first consultation, the patient receives the information sheets of the French Plastic Surgery Society (SOFCPRE) according to the proposed surgical treatment. The second consultation makes it possible to verify the pertinence of the surgical act, to reiterate the preoperative recommendations, to confirm that the information given to the patient was well understood and to obtain the written consent from the patient. The written consent should include the fact that the patient received the information sheets of the SOFCPRE, that they were read and understood, and that the surgeon has transmitted the necessary information in order for the patient to take an informed and free decision to pursue with the surgery. The follow-up after surgery is as important as the surgery itself. In some cases, cosmetic gestures can be performed in the following months to obtain the best results possible and the highest satisfaction. The face- and neck-lift is an "adventure" for the patients and the postoperative difficulties should not be underestimated. However, the caring and professional support of the plastic surgeon and the support of someone of the patients' entourage can help the patient overcome this stage, and obtain a maximum benefit after this operation.

[Incisions and baseline operative technique of cervicofacial lifting]. / Incisions et technique opératoire de base du lifting cervicofacial.

Cervicofacial lifting is one of the most iconic procedure of plastic surgery and is about hundred years old. In the following chapters of this report, numerous technical points will be specify. A baseline reliable and reproducible technique, appealing to the largest possible audience is presented in order to begin this surgery in optimum conditions. Pre- and postoperative management is also exposed. The aim of this chapter is to precise incisions and baseline operative technique of cervicofacial lifting, with description of SMAS and platysma suspensions as well as complementary procedures like liposuccion and lipofilling. This chapter will lay the foundation of more complex elements that will be described in the various following chapters.

[Face-lift surgery in ambulatory]. / Lifting cervicofacial en ambulatoire.

OBJECTIVE: The proposal is to demonstrate that facelift surgery is particularly suitable for the care in ambulatory. METHODS: Between 2010 and 2016, 246 patients were operated for a facelift in ambulatory. RESULTS: No major complication arose in this series (241). Among the patients, 98% expressed their satisfaction and would accept again this intervention in ambulatory. CONCLUSION: The facelift can be realized in ambulatory with complete safety. The rate of satisfaction shows a very strong support of the patients for the ambulatory care.

[Use of Harmonic blade in face lifting]. / Apport de l'ultracision dans les liftings cervico-faciaux.

INTRODUCTION: Rapid recovery and return to social activities are what every patient wishes when considering to undergo a face lifting procedure. In our practice, the use of the Harmonic scalpel in order to achieve this goal has greatly improved the postoperative period. PATIENTS AND METHODS: We have performed 920 face lifting procedures exclusively using the Harmonic scalpel from 2001 to May 2017. RESULTS: A retrospective chart review was performed. Mean operative time was 110minutes for facelift involving SMAS plication only, and 180minutes for facelift involving SMAS plication with the addition of submental approach for anterior platysma plasty. Return to normal social life was achieved on the 8th postoperative day for the majority of cases. CONCLUSION: The use of the Harmonic scalpel, once properly integrated in the face lifting procedure, significantly reduces postoperative ecchymosis and oedema and allows a prompt return to normal social life.

[Prevention of the post-surgical insatisfactions and possible medico-legal complications]. / Prévention des insatisfactions postopératoires et des éventuelles complications médico-juridiques.

The purpose of this work is to better understand the reasons for post-surgical instability and what makes up the bed of medico-legal complications. Beyond technical competence, it is essential to observe a very high degree of rigor in listening to the real motivations in order to give the most accurate possible surgical indications and in particular to know to detect and never to operate certain patients who, whatever we do, will always be dissatisfied. The quality of information is one of the essential elements of prevention: information is part of the care and there is no therapeutic success without a successful relationship between a caregiver and a carereceiver. Before the surgery, it is essential to pre-establish written proof of the proper delivery of the information by signing a receipt and an informed consent document. However, the information does not stop at the time of the operative gesture and it is necessary to be able to provide complete and timely information about any post-surgical complications. Furthermore, aesthetic medicine is well understood and rigorously implemented, contributes to the prevention of surgical and medico-legal complications, reducing the heaviness of certain surgical gestures. The question of e-reputation should in no way be neglected. From this point of view, prevention consists in controlling as much as possible the Internet environment. Indeed, where, in the past, in the presence of a dissatisfied patient awaited us, the fear of word-of-mouth or trial is added to the risk of harm E-reputation whose implications can be very damaging. At a time when the intensive use of the Internet allows anyone to get out of anonymity, we must also control these tools at the risk of sacrificing our expertise at the coronation of amateurs.

[The current views of the problem of the plastic correction of the laryngo-tracheal defects in the patients presenting with combined laryngeal stenoses]. / Sovremennyi vzgliad na problemu plastiki laringotrakheal'nogo defekta u bol'nykh s sochetannymi stenozami gortani.

The present review of the literature is designed to analyze the currently available methods for the plastic correction of the laryngo-tracheal defects in the patients presenting with combined laryngeal stenoses at the concluding stage of their medical rehabilitation. We looked through 56 literature sources including 28 publications of the foreign authors. The different approaches to the plastic correction of the laryngo-tracheal defects have been critically considered with special reference to their advantages and disadvantages. The importance of the problem under consideration arises from the necessity of the search for the new methods of plastic correction of the laryngo-tracheal defects.

Transverse cervical vessels as recipient vessels in oral and maxillofacial microsurgical reconstruction after former operations with or without radiotherapy.

BACKGROUND: The purpose of this study was to investigate the reliability and outcome of using the transverse cervical vessel (TCV) as a recipient vessel for microvascular reconstruction in patients whose vessels in the neck region are unavailable because of previous surgery or radiotherapy. METHODS: Between January 2012 and August 2014, secondary head and neck reconstruction was performed using the TCV as a recipient vessel in eight patients who had undergone previous neck dissection and radiation therapy (n = 5). Five patients had a recurrent carcinoma, one had undergone an operation for scar release and two had been treated surgically for a second primary cancer. The anterolateral thigh flap (ALT), anteromedial thigh flap (AMT), and fibular flap were used for the reconstruction. Clinical data were recorded for each patient. RESULTS: All of the ipsilateral transverse cervical arteries were found to be free of disease. The second free flap was revascularized using the TCVs (n = 6) or the external (n = 1) or internal (n = 1) jugular vein. The free flaps used for the reconstruction included the ALT flap (n = 6), AMT flap (n = 2), and fibular flap (n = 1). All of the flaps survived without vascular events, and the patients healed without major complications. The mean follow-up time was 11 months. One patient died of distant metastases during follow-up. CONCLUSIONS: In patients who have previously undergone neck surgery with or without radiotherapy, the TCVs are reliable and easily accessible recipient vessels for microsurgical reconstruction in the oral and maxillofacial region. If the transverse cervical vein is unavailable, the internal or external jugular vein should be dissected carefully to serve as an alternative for microvascular anastomoses.

Clip reconstruction of giant vertebral artery aneurysm after failed flow reduction therapy.

Flow reduction therapy is sometimes utilized for difficult aneurysms, but it does not always work. A 42-year-old man presented with headache, dizziness, and slight gait disturbance due to left thrombosed giant vertebral aneurysm. Clip ligation of the VA after the PICA origin was performed for flow reduction based on the CFD analysis. Two months later, the aneurysm showed minor hemorrhage and hydrocephalus, and thrombectomy and clip reconstruction of the VA was performed. He returned to work with slight ipsilateral facial palsy (House & Brackmann grade 2). The video can be found here: http://youtu.be/-AUVk6nxefQ.

Treatment of severe thyroid eye disease: a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS).

PURPOSE: To evaluate the current practice patterns for the treatment of severe thyroid eye disease (TED) in the United States by conducting a survey of the American Society of Ophthalmic Plastic and Reconstructive Surgery. METHODS: This is a questionnaire study. The survey encompassed the use of different modalities, including intravenous steroids, oral steroids, orbital decompression, orbital radiation, intraorbital steroid injections, and steroid-sparing biologic agents, in the treatment of severe TED. Specifics on the dosing regimens of steroids and types of decompression used were queried. RESULTS: With regard to treatments used "at all" in the management of severe TED, 87% use oral steroids and 74% use intravenous steroids. Eighty-three percent use orbital decompression, 70% use radiation, 33% use biologic agents, and 28% use intraorbital steroid injections. Oral steroids were slightly preferred to intravenous steroids at 43% versus 40% for first-line treatment. Most responders (61%) chose 2-wall decompression as their preferred technique. CONCLUSIONS: Severe TED can be a devastating disease leading to diplopia and vision loss. Treatment recommendations have varied and continue to evolve. The survey reported herein found that oral steroids were slightly preferred over intravenous steroids by the members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, most of who practice in the United States. This is in contrast to survey results from European and Latin American physicians, which more strongly favored intravenous steroids. In addition, orbital decompression and orbital radiation still play significant roles in the management of severe TED.

[Anatomical rationale for elevating revascularized ulnar forearm fasciocutaneous flap for head and neck reconstruction].

In this paper we studied in detail features of the blood supply to the tissues of the forearm of the pools ulnar and radial arteries, the technique of line access and the formation of skin-fascial ulnar flap by using a layered dissection with contrast vessels on non fixed human cadavers. Blood supply of the forearm carried out by branches radial and ulnar arteries, which allows to create in this area radial flap and ulnar flap loo. The size of the skin-fascial ulnar flap can reach 3-10 cm in length, 2-6 cm in width, the length of vessel pedicle of the transplant can reach 12 cm. The research studied the characteristics of blood supply of the forearm and the comparative evaluation of tissue perfusion of the radial and ulnar arteries; proved localization forming ulnar flap. Studies have shown that revascularised skin-fascial ulnar flap may be can be an alternative donor material for elimination of soft tissue defects with less traumatization donor area and reduce upper limb function compared with radial flap.

The role of colour duplex sonography in preoperative perforator mapping of the anterolateral thigh flap.

The anterolateral thigh (ALT) flap was first described in 1984. It is now widely used in reconstructive surgery following extensive tumour resection in head and neck cancer. Routine preoperative perforator mapping is recommended due to variability of the vascular anatomy of the flap. A wide array of diagnostic tools is available for this purpose, including colour duplex sonography (CDS). In this study, we report our experience with CDS. The number, location, and course (myocutaneous or septocutaneous) of ALT perforators were assessed by CDS prior to reconstructive surgery in 22 patients with head and neck cancer. These data were compared with the intraoperative anatomical findings to assess agreement and reliability. The positive predictive value and sensitivity of CDS in detecting perforator location was 89.4 and 94.4%, respectively, when compared to the surgical report. CDS also identified the perforator course with 100% accuracy. Colour duplex sonography is an effective, non-invasive, and relatively inexpensive technique for assessing the location of skin perforators.

Reconstruction of cervical scar contracture using axial thoracic flap based on the thoracic branch of the supraclavicular artery.

PURPOSE: Cervical scar contracture causes both physical and psychological distress for burn patients. Many pedicle flaps or skin grafting have been suggested for reconstruction of cervical scar contracture with variable results in the literature. The authors present the axial thoracic flap based on the thoracic branch of the supraclavicular artery (TBSA) for reconstruction of cervical scar contracture. METHODS: Postburn scar contractures in anterior neck region of 66 patients had been reconstructed with the axial pattern thoracic flaps based on the TBSA, including 1 expanded and 10 nonexpanded pedicle flaps, and 9 expanded and 46 nonexpanded island pedicle flaps, during 1988 through 2012. After removing and releasing the cervical scar contracture, the flap was designed in the thoracic region. The axial artery of the flap is the TBSA bifurcating from the intersection point of sternocleidomastoid muscle and omohyoid muscle with several concomitant veins as the axial veins. The flap can be designed in a large area within the borders of the anterior border of the trapezius muscle superiorly, the middle part of the deltoid muscle laterally, the midsternal line medially, and the level 3 to 4 cm below nipples inferiorly. After incisions were made along the medial, inferior, and lateral border, dissection was performed toward the pedicle. Donor site was closed directly in expanded cases and with skin grafting in nonexpanded cases. RESULTS: Cervical scar contractures were repaired with good functional and cosmetic results in 64 cases among this cohort. Flap tip necrosis in other 2 cases, caused by postoperative hematoma, was repaired by skin grafting. The color and texture of all flaps were fitted with those of the surrounding skin. The donor sites all healed primarily. The flap sensation in the thoracic region regained in the early stage postoperatively and that in cervical area recovered completely after 6 months according to the report of the patients. CONCLUSION: With reliable blood supply based on the dissection of cadavers, axial flap based on the TBSA is a good option for reconstructing severe cervical scar contracture.

Pre-expanded thoracodorsal artery perforator-based flaps for repair of severe scarring in cervicofacial regions.

BACKGROUND: Reconstruction of cervicofacial scarring continues to present challenges for surgical treatment. Here we present our clinical experience in repairing cervicofacial scarring using pre-expanded thoracodorsal artery perforator flaps. METHODS: From January 2007 to December 2012, 15 patients were treated for severe cervicofacial scarring. In the first surgical stage, expanders were implanted subcutaneously in the zone nourished by thoracodorsal artery perforators. The expansion generally took 3 to 6 months. In the second surgical stage, the cervicofacial cicatricial contracture was released and the secondary defect was covered with local flaps. The remaining wound was covered by the free thoracodorsal artery perforator expanded flap, which was anastomosed to the facial vascular bundle. The donor site was closed directly in all the patients. RESULTS: The postoperative follow-up time ranged from 1 to 5 years. The deformities were corrected, all flaps survived completely and none were bulky. The maximum length of the flaps was 32 cm (mean, 22.4 ± 4.2 cm), and the maximum width was 17 cm (mean, 14.4 ± 2.2 cm). All patients exhibited recovery of neck movement, and there was no recurrence of neck contracture. CONCLUSION: The pre-expanded thoracodorsal artery perforator flap is an ideal method for reconstruction of severe cervicofacial cicatricial contracture.

Defining the fat compartments in the neck: a cadaver study.

BACKGROUND: Cervicoplasty is an important component of aesthetic facial and neck surgery, but the fat content in this area has not been described. OBJECTIVES: The authors identify anatomic compartments of fat in the neck (specifically the areas relevant to surgical management), quantify the fat in each compartment, and describe the relationships between each compartment and the submandibular glands. METHODS: The skin was removed from 10 fresh cadaver heads. Each compartment of fat was weighed, along with the submandibular gland. Supraplatysmal fat was found between the skin and the platysma muscle, and it was compartmentalized into suprahyoid and infrahyoid fat. Subplatysmal fat was found deep to the platysma and between the medial edges of the anterior digastric in the midline; this fat also fell into suprahyoid and infrahyoid compartments. The "very deep" fat was deep to the anterior digastric muscles and submandibular gland, and adherent to the strap muscles. RESULTS: On average, supraplatysmal fat represented 44.7% of the fat in the neck, the subplatysmal fat represented 30.7%, and the submandibular gland represented 24.5%. The very deep fat was scant, representing less than 1% of the fat in the neck. CONCLUSIONS: This anatomic study provides a comprehensive review of fat in the neck, and the results should serve as an additional guide as surgeons approach this challenging area in surgical rejuvenation.